Question

WRITE A CARE PLAN FOR A CLIENT WITH - PNEUMONIA

(NOTE - CLIENT HAS A TRACH COLLAR IN PLACE AND ALSO COMPLAINED OF SEVERE SHORTNESS OF BREATH.)

- CLIENT HISTORY / DEMOGRAPHICS -

Male 40 y/o , Hispanic

Abdominal sepsis , diabetes type 2 , had a CODE BLUE event , HTN, ascites, peritonitis, client is lethargic.

- VITAL SIGNS -

Temp - 98.3 * c

Pulse - 67

RR - 20

BP - 154/83

Write a care plan -

3 Goals needed (long term and short term)

3 Nursing diagnosis with rationale

5 Nursing intervention for each Nursing Diagnosis.

Answer 1

Here in the present scenario, a 40-year-old Hispanic patient is suffered from pneumonia in the medical emergency and had a tracheostomy collar in place and has a history of abdominal sepsis, diabetes type 2, HTN, ascites, peritonitis, and is lethargic.

*Ineffective Breathing Pattern related to hypoxia as evidence by shortness of breath

Nursing Diagnosis Statement	Expected Outcome	Nursing Intervention	Evaluation
Ineffective Breathing Pattern related to hypoxia as evidence by shortness of breath secondary to pneumonia	*Pt oxygen saturation will be 90-100% throughout hospitalization. * After the proper intervention, the client will establish an effective respiratory pattern *The patient will show more comfort than previous	*Auscultate the chest periodically to evaluate the breath sounds and presence for any secretions *Ensure a proper positioning of the client to avoid exacerbation of breathing difficulty *Check the saturation of the patient periodically *Administer oxygen if needed or prescribed.	*Saturation is maintained at a level of 98-99%. *The patient shows more comfort while breathing *During the auscultation, the chest is clear without any abnormal breath sounds or secretions

*Fatigue related to the poor physical condition

Nursing Diagnosis statement	Expected Outcomes	Intervention	Evaluation
Fatigue related to the poor physical condition secondary to less intake and tracheostomy	*To reduce the weakness *To improve the physical well being *The patient can able to identify the factors that result in weakness.	*Search for the aggravating factors that result in weakness of the patient *Feed the items that can be in liquid form instead of pure solid, that may interfere with swallowing due to the placement of tracheostomy collar *Encourage the client to express the feeling of weakness. *While communicating with the client use the method of active listening techniques and identify the source	*Patient verbalized feelings of increased energy and improved well being *Patient is able to identify the factors that aggravate the weakness *Patient shows a more positive attitude

*Risk for decreased cardiac output related to increased vascular constriction

Nursing Diagnosis Statement	Expected outcome	Intervention	Evaluation
Risk for decreased cardiac output related to increased vascular constriction secondary to ascites	*The patient will maintain an acceptable level of blood-pressure after the proper intervention * The patient will demonstrate a cardiac rhythm to an acceptable range * To improve the physical well being of the client	*Monitor the Bloop pressure periodically and alternatively measure on both hands *Note presence of, quality of central and peripheral pulses. *Auscultate heart tones and breath sounds *Administer antihypertensives as prescribed *Monitor response to medications to control blood pressure	*The patient maintain a B.P to a range of 136/80 mmHg *The patient demonstrates regarding an acceptable cardiac rhythm. *The patient is not showing any symptoms of agitation